How first responders, especially the fire service, are teaming up with human service professionals to tackle safety issues related to compulsive hoarding.

BY STEPHANIE SCHOROW

It was a fire that alarmed an entire city: a blaze in a high-rise Toronto public housing complex that defied massive efforts to bring it under control. "I remember saying, ‘When is this going to go out?’," recalled Toronto Fire Chief William Stewart, who had anticipated a routine apartment fire, not a six-alarm inferno.

The 30-floor, 713-unit building was located on Wellesley Street in downtown Toronto. The fire began around 5 p.m. on September 24, 2010, when a cigarette was dropped from an upper floor into the west-facing balcony of a unit on the 24th floor. As firefighters would soon learn, unit 2424 was no ordinary household. The 560-square-foot (52-square-meter), one-bedroom apartment was stuffed with paper and possessions, and the balcony where the fire started was just as packed.

Fanned by winds with temperatures in the high 80s, the balcony fire spread into the apartment. A fire alarm was initiated, and the first units from the Toronto Fire Department responded. Arriving firefighters were prevented from getting into the unit by the high heat in the hallway; the building was constructed in the 1960s and was unsprinklered, allowing the fire to grow rapidly. The high fuel load in the apartment soon turned the hallway into what one fire expert called "a tunnel of hell." The radiant heat was so intense that the door of the unit across the hall began to burn.

Toronto Fire Chief William Stewart faces local media as an apartment fire continues to burn above him. The fire, which occurred in a unit with hoarding conditions, took more than six hours to bring under control and forced the evacuation of more than 1,200 residents.Photograph: Newscom

As firefighters helped evacuate the building’s more than 1,200 residents, some of whom were trapped by smoke on upper floors, Stewart had to devise a strategy for getting to the source of the fire in the unit. Standard 38-millimeter (1.5-inch) hose lines were not sufficient to suppress the fire, and Stewart called for deployment of 65-millimeter (2.5-inch) hand lines as well as a ground monitor, a portable unit that created a single massive stream. The monitor is usually deployed on aerial ladders from the outside of buildings, but the extra water power was now needed inside.

Using fine streams of water to keep themselves cool, firefighters again pressed toward unit 2424. When they finally reached the door, which by now was partially burnt, they discovered that the contents of the apartment were pressing against the door, preventing them from getting in. Eventually firefighters were able to push the door open and focus the full force of the stream on the fire raging inside. Firefighters were able to contain the fire to the 24th floor unit and corridor, but it was not brought under control until about 11:30 p.m., and only after huge amounts of water had been discharged. The all-clear was not given until 1 a.m.

By the time it was over, more than 300 firefighters had been on the scene. As Stewart would later write in a Canadian firefighting journal, "I had never witnessed an apartment fire that required firefighting operations over [such] a prolonged period."

Three firefighters and 14 residents, three of whom had serious injuries, were treated at local hospitals. The occupant of unit 2424, a man in his late 50s, was not among them; he was not at home at the time of the fire. Due to structural concerns, residents were ordered to vacate the building, leaving them temporarily homeless. The cost of the damage, which included structural damage to the unit and balcony, ran into the hundreds of thousands of dollars, according to the Toronto Fire Department.

Another shock awaited Stewart. After the fire had been extinguished, firefighters went door to door throughout the building in a secondary sweep to ensure all occupants were safely evacuated. Stewart said they found another 14 units packed with possessions — not to the extent of unit 2424, but, as Stewart said, "it was the same problem."

The problem was a severe version of what is known as compulsive hoarding, a psychological condition in which people accumulate or are unable to discard possessions. In an extreme case like the Wellesley Street fire, the sheer volume of chaotically arrayed material was sufficient to create a serious threat of blocked occupant egress, difficult access for first responders, easier ignition or a greater chance of rapid or severe fire growth, and even structural collapse. Stewart, like many firefighters, had fought fires in hoarding households before, but he’d never seen a situation like the one he witnessed on September 24.

In response, an alarmed Toronto Fire Marshal’s office issued statements urging landlords and property owners to inform local fire departments of instances of hoarding where they believe it poses a fire safety risk. The fire has prompted Stewart to speak out in workshops and meetings to raise awareness that compulsive hoarding can be dangerous not only for residents and their neighbors, but for first responders. "Our guys and ladies took a hell of a beating," he said of the Wellesley Street fire. "They shouldn’t be taking that beating."

Compulsive hoarding isn’t new, but a growing awareness of the problem — and changing public attitudes toward it — may allow firefighters to play a significant role in recognizing and even ameliorating dangerous hoarding situations. "Firefighters and public fire safety educators in the United States and Canada are often faced with challenges on the best ways to prevent fires related to hoarding,’’ said Sharon Gamache, NFPA’s (former) program director for high-risk outreach programs. "No one wants to see injuries or loss of life among civilians or firefighters as a result of fire hazards that may exist in hoarding situations."

This means more training for the fire service, Stewart said, but it’s a necessary effort. "If we’re not trained," he said, "then we’re not acting in the service of people we’re sworn to protect."

Beyond the ‘Collyer Mansions’

For decades firefighters have talked of "Collyer mansions," a reference to the wealthy and eccentric brothers who were found dead in 1947 in their New York City mansion that was filled with an estimated 130 tons of possessions, junk, and garbage. Veteran firefighters have traded stories about homes so packed with furniture, clothing, magazines, newspapers, toys, and other items that they had trouble gaining entry during fires, and that residents could not be found amid their heaps of possessions.

Since many hoarders were elderly, it was often assumed they were reacting to Depression-era privations by holding on to every rubber band, plastic container, or broken appliance; psychologists saw hoarders as suffering from obsessive-compulsive disorder (OCD).

Beginning in the 1990s, though, social scientists began to isolate compulsive hoarding as a distinct disorder, where people get a kind of "high" from obtaining possessions and suffer severe anxiety over discarding them. Studies also showed that the condition cut across age ranges, ethnicities, and socio-economic lines.

Social service agencies are diagnosing an increasing number of hoarding cases around the country, in part due to heightened awareness of the problem, according to Gail Steketee, the dean of the School of Social Work at Boston University. Steketee, along with Smith College psychology professor Randy Frost, is a pioneer in diagnosing and treating hoarding; their book, Stuff: Compulsive Hoarding and the Meaning of Things, was published in 2010.

Steketee points to a trio of major epidemiological studies in the 1990s that helped establish the scope of hoarding in modern society. The studies, conducted in the United States, the United Kingdom, and Germany, all indicated that between three and five percent of the population — as many as 15 million Americans — are compulsive hoarders. Frost says that a small percentage of compulsive hoarders, perhaps 10 percent, live in squalid or unsanitary conditions.

Because these studies were conducted in the 1990s, Steketee said, researchers can’t say if the incidence of hoarding is increasing or decreasing. "We do know the world is much more aware of the problem," she said. "With any luck, with the efforts underway we will see some decrease over time, especially as we try to get the word out to young people who are developing the problem, so they can prevent themselves from getting in trouble later in life."

Popular media has, in some ways, turned hoarding into the social problem du jour. Over the last few years, television series like A&E’s Hoarders and TLC’s Hoarding: Buried Alive have highlighted people who fill their homes, yards, and storage units with belongings that most people would consider junk. Another program, Animal Planet’s Confessions: Animal Hoarding, specializes in a subset of compulsive hoarders. All of the series illustrate how deeply hoarding behavior is ingrained, as the subjects risk eviction, personal safety, and the loss of marriages and family ties in their efforts to hold on to their stuff, or to their critters. Leery at first of the sensational nature of the programs, Steketee conceded they can help educate the public and can show that treating hoarding "is not a quick fix."

Such media attention underscores how compulsive hoarding goes beyond mere poor housekeeping or the orderly accretion of items by avid collectors. Experts in the field acknowledge there’s a significant difference between someone who simply has a lot of stuff and people whose possessions are overwhelming their lives and creating potential health and safety hazards. "I’ve been to homes where someone collects toys, like Barbies," said John E. Concha, fire inspector for the El Paso (Texas) Fire Department, who has spearheaded efforts to raise awareness of hoarding. "They can tell you where everything is. It’s cluttered, but there’s some kind of organization to it."

By contrast, a compulsive hoarder’s home is often chaotic, Concha said, with heaps of material in no discernable order. In extreme cases, doors and windows are blocked, impeding entrance or exit in an emergency. Residents are forced to crawl over, or tunnel through, their possessions in order to move about their homes.

A particular concern of the fire service is the chaotic nature of the material in many hoarding households, where blocked windows and exits can make fire attack and rescue difficult. Photograph: Newscom

It’s this element of chaos, and the safety issues it presents to residents and first responders, that most clearly distinguishes the problem of compulsive hoarding. The fundamental characteristics of compulsive hoarding can also lead to a host of related problems, including unorthodox use of utilities. People who are embarrassed about their homes and overwhelmed by the prospect of cleanup sometimes decline to call plumbers or electricians when problems develop; hoarding homes can exist without functioning refrigerators, toilets, and furnaces, with residents resorting to bottled water, space heaters, and candles, adding to the potential hazards. Concha was recently called to a home he described as pristine on the outside but "one giant closet" on the inside. There was no running water or electricity; the occupant, a prominent nursing instructor, was sleeping on the porch and cleaning herself with antiseptic pads, which she also failed to discard.

One man’s treasure is another’s firetrap

While the relationship between hoarding and fire safety has yet to be fully documented — NFPA, for example, does not maintain specific data on hoarding-related fires — the work of social scientists and the anecdotal reports of the fire service are gradually combining to reveal an important fire threat.

A 2009 Australian studyfound that hoarding fires are tougher to fight, and are far deadlier, than other types of residential fires. The data show that fires in hoarding homes have similar ignition sources as other fires, but that packed rooms can significantly complicate the fire attack. Basic rules of firefighting may not apply; firefighters are trained to look for the seat of the fire, but a hoarding household may present firefighters with a logistical nightmare, forcing them to wade through or crawl over stuff in an effort to find the ignition source. "You can’t search the normal way," noted Bill Cummings, a captain in the Shrewsbury (Massachusetts) Fire Department and a 35-year veteran firefighter. "You can’t find the walls because there’s too much stuff. You wouldn’t even know where you were if the place were filled with smoke."

The greatest risk, however, may be the fuel load itself, as demonstrated by the Toronto high-rise fire. Thirty years ago, the flashover point in most North American homes occurred after 28 to 29 minutes, Stewart said. Now, due to increased use of plastics and synthetics in clothing, furniture, and other household items — including those gathered as part of a hoarding trove — the flashover point may occur in as little as three minutes, he said. When faced with a hoarding situation where access to a home is difficult because there’s so much stuff inside, an incident commander must weigh the added risk when considering whether to send firefighters in. That added caution could mean anyone trapped inside stands a lesser chance of rescue or survival.

In the last decade, fire service personnel have become increasingly aware of the problems of hoarding and, to borrow a phrase, if they see something, they say something. Concha and Stewart are among the fire service professionals who are organizing workshops and presentations designed to alert professionals to the signs of hoarding, and to discuss appropriate responses. In Toronto, a multi-divisional hoarding committee, which meets monthly, is hammering out a standard response for non-emergency hoarding conditions. "It’s not just for the fire risk — the people need help," said Toronto Deputy Chief Frank Lamie. "Usually if you clean a place out, they just stockpile it again."

Compulsive hoarders can be helped, but it may take a variety of professionals, ranging from mental health counselors to building inspectors, to devise a working plan for addressing issues. "You need a multi-disciplinary response," said Kenneth R. Willette, NFPA division manager of Public Fire Protection and a former fire chief. "You can’t do it without that approach." Willette stresses that people who are compulsive hoarders are not, in most cases, acting maliciously, but can become overwhelmed by the prospect of cleanup and may be too embarrassed to ask for help. "It’s simply an indication of their inability to care for themselves and maintain their living space in a manner that we feel would be safe," he said.

That’s why the fire service is increasingly teaming with social agencies to address those challenges. About 85 communities around the country have organized hoarding task forces, according to Christiana Bratiotis, a post-doctoral fellow at the Hoarding Research Project at Boston University. Those task forces usually include building inspectors, social workers, elderly-service workers, social psychologists, animal control officers, and first responders — including police, emergency medical teams, and firefighters — who work together to offer multiple services to compulsive hoarders. Hoarding problems are brought to these task forces by any number of means, including an alarmed relative who calls the police, a cable TV repairman who alerts social services, or neighbors who complain to city inspectors about odors, too many pets, or trash in yards.

Even when hoarding poses immediate threats, it can be intensely difficult to change human behavior. It is often not enough to order a cleanup, even when a building inspector or landlord uncovers violations. Often compulsive hoarders don’t see a problem; they resist all offers of assistance, even when faced with eviction or condemnation of their homes. Owners of large apartment complexes and managers of public housing have legal remedies to order clean-ups or evict residents when hoarding violates leases or poses health and safety risks. But in private homes, if there are no children or pets at risk, officials have little recourse to mandate cleanups; there is no legal requirement to report hoarding, unlike, say, child abuse, Willette said. Cooperation with the occupant is needed, a challenge that experts like Steketee describe as the most common difficulty they encounter when dealing with compulsive hoarders.

It’s often firefighters, called to a home for problems that have nothing to do with hoarding, that are the first to discover unsafe living conditions and who can help remedy the situation. First responder professionals play important roles in the early identification of serious problems due to hoarding, according to The Hoarding Handbook (Oxford Press, 2011), co-written by Bratiotis, along with Steketee and Cristina Sorrentino Schmalisch. The book is a nuts-and-bolts guide specifically written for human service professionals and first responders on how to assess and provide assistance in extreme hoarding situations. "Firefighters, as are all first responders, are really key in early intervention," Bratiotis said. "Unlike police officers, firefighters are generally seen by the public as good guys. They are in a very powerful position to leverage that relationship with people."

Bratiotis singles out Cummings, the veteran firefighter from Massachusetts, as a pioneer for his ability to reach out to occupants in unsafe homes and encouraging them to make changes. "Because he’s a firefighter and he’s a nice guy, people will say to him, ‘You can come in. Not any one else but you can come in.’ "Cummings has worked with his town’s hoarding task force for the past five years. His first task force case was an impeccably dressed elderly woman named "Gloria." Church friends of Gloria’s had contacted authorities, concerned that her home and car were overly filled with possessions. On hisinitial visit, Cummings found her condominium so packed with stuff that he wondered where Gloria slept at night. He could smell, but not see, her four cats among the clutter. He immediately recognized the fire hazards, and recalled approaching the woman with compassion. "I told her, ‘Gloria, if anything ever happened to you, how could we get you out of here? We wouldn’t be able to come through a window,’" Cummings said. "And she listened." Cummings was able to help Gloria make the house safer, and she gave the cats up for adoption. She continues to work on clean-up. "When I see her on the street," Cummings said, "she gives me a big hug."

This is an approach advocated by Julie Harris, a Community Ageing Strategist for the Metropolitan Fire and Emergency Services Board in Melbourne, Australia, a district that currently encounters a hoarding situation every seven to 10 days. Rather than alarm residents with offers or threats of a total clean-up, efforts should be made to target key risk areas, such as stoves, heaters, exits, and other danger areas in a residence, she said. Forced removal of material doesn’t necessarily help, since compulsive hoarders just replace it. The goal, she said, should be to return functionality to the home while reducing risk and building trust with the residents. Harris said the Melbourne department has commissioned a follow-up hoarding study.

A woman with a hoarding disorder receives assistance from a case manager from an outreach program near Toronto. Such services are partnering with the fire service to identify people with hoarding problems and work with them to clear clutter from their homes. Photograph: Newscom

With education sessions on hoarding scheduled for its annual meeting in Las Vegas in June, NFPA is joining the ranks of other grassroots efforts committed to educating first responders and others on this complicated issue. "This is not a typical fire service mission," Willette noted. "It’s crossing the line from fire suppression to social services. That’s a change in the mission of the fire service but it is borne out of necessity. It’s a reflection of the risks seen in society that the fire service accepts."

Stephanie Schorow is editor of Boston’s Fire Trail: A Walk Through the City’s Fire and Firefighting History. Top Photograph: Newscom